Provider Demographics
NPI:1073694949
Name:DE MESA, ISABELITA T (MD)
Entity Type:Individual
Prefix:DR
First Name:ISABELITA
Middle Name:T
Last Name:DE MESA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 459 RT 16
Mailing Address - Street 2:MAIN STREET
Mailing Address - City:WAR
Mailing Address - State:WV
Mailing Address - Zip Code:24892-0459
Mailing Address - Country:US
Mailing Address - Phone:304-875-4724
Mailing Address - Fax:304-875-4724
Practice Address - Street 1:RT 16 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WAR
Practice Address - State:WV
Practice Address - Zip Code:24892-0459
Practice Address - Country:US
Practice Address - Phone:304-875-4724
Practice Address - Fax:304-875-4724
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13434207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0049844000Medicaid
D49359Medicare UPIN
WV0049844000Medicaid